IFT08 - Complex Endovascular Aortic Repair After Failed EVAR: Clinical Outcomes and Impact on risk of Spinal Cord Injury

Objectives: To compare outcomes between patients undergoing fenestrated or branched endovascular aortic repair (F/B-EVAR) after failed EVAR versus primary F/B-EVAR and to investigate whether previous EVAR correlates with reduced spinal cord injury (SCI) incidence.

Methods: A retrospective analysis was conducted on 266 consecutive F/B-EVAR procedures performed at a tertiary aortic center between September 2011 and December 2024. Patients were divided into two groups: primary repair (Group A, n=180, 68%) and F/B-EVAR after failed EVAR (Group B, n=86, 32%). Clinical characteristics, procedural details, and outcomes were compared between groups.

Results: Mean age was 74±8 years, with no significant difference between groups. Female patients were significantly more prevalent in Group A (P=0.008). Group A had a higher prevalence of smoking (P=0.001) and COPD (P=0.002), while Group B showed higher rates of atrial fibrillation and anticoagulation use (P < 0.001). Aneurysms were significantly larger in group B (73±18 vs 64±11 mm, P< 0.001). Thoracoabdominal aneurysms were more frequent in Group A (P < 0.001), while pararenal aneurysms predominated in Group B (P=0.001). Fenestrated endografts were more commonly used in Group B (P=0.003), while branched devices were preferred in Group A (P=0.04). Planned multistage procedures for SCI prevention were performed in only 10 patients (4%), with 2 patients (2%) from Group B. Notably, all cases of SCI (n=10) occurred in Group A, with no cases in Group B (P=0.015). Mean postoperative stay was 10±12 days, with no between-group differences. No significant differences were found in rates of stroke, cardiac, pulmonary, or renal complications, vascular-related reinterventions, target visceral vessel patency, or instability. While clinical success, in-hospital and 30-day mortality rates were similar between groups, long-term survival analysis revealed significant differences (p < 0.001). Group B showed lower survival rates, with mean survival time of 35.7 months versus 57.1 months in group A.

Conclusions: Patients undergoing F/B-EVAR after failed EVAR represent a distinct population with different clinical and anatomical characteristics compared to primary F/B-EVAR patients. While the presence of a previous infrarenal endograft appears to provide protection against SCI, these patients demonstrate lower long-term survival rates. Despite similar perioperative outcomes and clinical success rates between groups, the marked difference in survival suggests that failed EVAR status might be an important prognostic factor to consider and different SCI prevention protocols might be needed for primary versus failed EVAR cases.